HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

The Protector Rider can only be bought along with the Base Plan and cannot be bought in isolation or as a
separate product. The Rider is subject to the terms and conditions stated below and also the Policy terms,
conditions, exclusions and applicable endorsements of the Base Plan. This Rider shall be available only if
the same is specifically mentioned in the Policy Schedule.
SECTION A. OTHER IMPORTANT TERMS YOU SHOULD KNOW
The terms defined in the Base Plan and at other junctures in the Policy Wording have the meanings
ascribed to them wherever they appear in this Policy and, where appropriate, references to the singular
include references to the plural; references to the male include the female and references to any
statutory enactment include subsequent changes to the same. All terms are subject to the terms defined
in the Base Plan and additional terms defined below.
I. Standard Definitions
Def. 1. Cashless facility means a facility extended by the insurer to the insured where the payments,
of the costs of treatment undergone by the insured in accordance with the policy terms and
conditions, are directly made to the network provider by the insurer to the extent pre-
authorization approved.
Def. 2. Condition Precedent means a policy term or condition upon which the Insurer’s liability under
the policy is conditional upon.
Def. 3. Day Care centre means any institution established for day care treatment of illness and/or
injuries or a medical setup within a hospital and which has been registered with the local
authorities, wherever applicable, and is under the supervision of a registered and qualified
medical practitioner AND must comply with all minimum criteria as under—
- has qualified nursing staff under its employment;
- has qualified medical practitioner/s in charge;
- has a fully equipped operation theatre of its own where surgical procedures are carried out;
- maintains daily records of patients and will make these accessible to the insurance company’s
authorized personnel
Def. 4. Disclosure of information norm means the policy shall be void and all premiums paid
hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or
non-disclosure of any material fact.
Def. 5. Grace Period means the specified period of time, immediately following the premium due date
during which premium payment can be made to renew or continue a policy in force without loss
of continuity benefits pertaining to waiting periods and coverage of pre-existing diseases.
Coverage need not be available during the period for which no premium is received. The grace
period for payment of the premium for all types of insurance policies shall be: fifteen days
where premium payment mode is monthly and thirty days in all other cases. Provided the
insurers shall offer coverage during the grace period, if the premium is paid in instalments
during the policy period. (Note: In case of non-instalment premium payment, coverage shall not
be available for the period for which no premium is received).

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 1

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

Def. 6. Hospital means any institution established for in-patient care and day care treatment of illness
and/or injuries and which has been registered as a hospital with the local authorities under the
Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments
specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum
criteria as under:
• has qualified nursing staff under its employment round the clock,
• has at least 10 in-patient beds, in towns having a population of less than 10,00,000 and 15
in-patient beds in all other places,
• has qualified Medical Practitioner(s) in charge round the clock,
• has a fully equipped operation theatre of its own where surgical procedures are carried out,
• maintains daily records of patients and will make these accessible to the insurance
company’s authorized personnel.
Def. 7. Hospitalisation or Hospitalised means admission in a Hospital for a minimum of 24
consecutive ‘in-patient’ hours except for specified procedures / treatments, where such
admission could be for a period of less than 24 consecutive hours.
Def. 8. Inpatient Care means treatment for which the Insured Person has to stay in a Hospital for
more than 24 hours for a covered event.
Def. 9. Network Provider means Hospitals or health care providers enlisted by an insurer, TPA, or by
a TPA and insurer together to provide medical services to an insured by a cashless facility
Def. 10. Non Network means any Hospital, day care centre or other provider that is not part of the
Network.
Def. 11. Non-instalment Premium Payment refers to payment of premium for the entire policy period
made in advance as a single premium.
Def. 12. Notification of Claim means the process of notifying a claim to the insurer or TPA through
any of the recognized modes of communication.

II. Specific Definitions

Def. 1. Base Plan means any retail indemnity health Insurance policy issued by HDFC ERGO General
Insurance Company Limited including its terms and conditions, any annexure thereto and the
Policy Schedule (as amended from time to time), the information statements in the proposal
form and the Policy wording (including endorsements, if any) and to which this Rider is
attached.
Def. 2. Bank rate shall mean the rate fixed by the Reserve Bank of India (RBI) at the beginning of the
financial year in which claim has fallen due.
Def. 3. Commencement Date means the commencement date of this Policy as specified in the
Schedule.
Def. 4. Dependents means only the family members listed below:
i) Your legally married spouse as long as she continues to be married to You;
ii) Your children Aged between 91 days and 25 years if they are unmarried
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 2

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

iii) Your natural parents or parents that have legally adopted You, provided that the parent was
below 65 years at his initial participation in this Policy.
iv) Your Parents -in-law as long as Your spouse continues to be married to You and were below
65 years at his initial participation in this Policy.
All Dependent parents must be financially dependent on You.
Def. 5. Dependent Child means a child (natural or legally adopted), who is unmarried, aged between
91 days and 25 years, financially dependent on the primary Insured or Proposer and does not
have his / her independent sources of income.
Def. 6. Family Floater means a Policy described as such in the Schedule where under You and Your
Dependents named in the Schedule are insured under this Policy as at the Commencement
Date. The Sum Insured for a Family Floater means the sum shown in the Schedule which
represents Our maximum liability for any and all claims made by You and/or all of Your
Dependents during the Policy Period.
Def. 7. Insured Person means You and the persons named in the Schedule.
Def. 8. Material Facts means all relevant information sought by the Company in the Proposal Form
and other connected documents to enable it to take informed decision in the context of
underwriting the risk.
Def. 9. Policy Period means the period between the Commencement Date and the Expiry Date
specified in the Schedule.
Def. 10. Policy Year means a year following the Commencement Date and its subsequent annual
anniversary.
Def. 11. Renewal means the terms on which the contract of insurance can be renewed on mutual
consent with a provision of grace period for treating the renewal continuous for the purpose of
gaining credit for
Def. 12. Pre-Existing Diseases, time-bound exclusions and for all waiting periods.
Def. 13. TPA means the third party administrator that We appoint from time to time as specified in the
Schedule.
Def. 14. We/Our/Us means the HDFC ERGO General Insurance Company Limited.
Def. 15. You/Your/Policyholder means the insured person named in the policy Schedule who is
insured under the policy.
SECTION B. BENEFITS
Please Note: Any claim under any of the benefits mentioned in this rider Policy will only be admissible
when it qualifies according to the terms, conditions and exclusions in the Base Plan.
A. Claim Protector
If a claim has been accepted under the Base plan, then the items which are not payable under the Base
Plan as per the List of Excluded items released by IRDA (Refer Annexure 1) related to the particular claim
will become payable. The maximum claim payout under this benefit shall be limited to Base Sum Insured
under Base Plan.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 3

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

B. Sum Insured Protector

The Sum Insured protector is designed to protect Your Sum Insured against rising inflation by linking the
Basic Sum Insured under the Base Plan to the Consumer Price index (CPI).
The Basic Sum Insured will be increased on cumulative basis at each renewal on the basis of inflation rate
in previous year. Inflation rate would be computed as the average CPI of the entire calendar year
published by the Central Statistical Organisation (CSO).
The % increase will be applicable only on Basic Sum Insured under the Policy and not on any other
benefit which leads to increase in Sum Insured.

What is Consumer Price Index (CPI)?

CPI is a measure of inflation, changes in the CPI are used to assess price changes associated with the
cost of living.
It is a measure that examines the weighted average of prices of a basket of consumer goods and
services, such as transportation, food and medical care. It is calculated by taking price changes for
each item in the predetermined basket of goods and averaging them.
The Central Statistics Office (CSO) is a government agency in India under the Ministry of
Statistics and Programme Implementation responsible for co-ordination of statistical activities in India,
and evolving and maintaining statistical standards.

Illustration:
Consider an Insured Person is having a Base plan of Rs.5 Lakhs and along with Base plan he/she
purchases this rider.
Policy Year Year 1 Year 2 Year 3 Year 4
Basic Sum Insured (in Rs.) 500,000 500,000 500,000 500,000
CPI Linked inflation Rate (%) 6% 5% 5% -
Total Sum Insured (in Rs., at 500,000 530,000 556,500 584,325
beginning of the year) (6% X (5% X (5% X 556,500)
500,000) 530,000)

In case of Sum Insured enhancement or reduction at the time of renewal, any accumulated sum Insured
due to Sum Insured Protector Benefit will be added to the enhanced or reduced Sum Insured opted by
Insured at the time of renewal.
Referring to above illustration,
Consider Insured opts to Consider Insured opts to decrease
increase the Sum Insured to Rs. the Sum Insured to Rs. 3 Lakhs at
10 Lakhs at the time of renewal the time of renewal in Year 4
in Year 4
Basic Sum insured (in Rs.) 1,000,000 300,000
Accumulated Sum Insured 84,325 84,325
Protector Benefit (in Rs.) ( 584,325 – 500,000) ( 584,325 – 500,000)

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 4

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

Total Sum Insured (in Rs., at 1,084,325 384,325

beginning of Year 5)

*Accumulated Sum Insured Protector Benefit = Total Sum Insured at beginning of Year 4 - Total Sum
Insured at beginning of Year 1
Please Note that all the accumulated Sum Insured Protector benefit will lapse and your Sum
Insured under Base Plan will roll back to the Basic Sum Insured opted under the Base Plan if
this rider Policy is not renewed.
SECTION C. GENERAL EXCLUSIONS
All exclusions as mentioned in the Base Plan unless otherwise stated and covered in Section B of Protector
Rider policy wordings.
Section D. General Terms & Conditions

I. Standard General Terms & Conditions

A. Premium Payment in Instalments
If the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly,
Quarterly or Monthly, as mentioned in the policy Schedule/Certificate of Insurance, the following
Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)
i. Grace Period of 15 days would be given to pay the instalment premium due for the policy.
ii. If premium is paid in instalments then coverage will be available during the grace period
also. (Note: In case of non-instalment premium payment, coverage shall not be available for
the period for which no premium is received).
iii. The insured person will get the accrued continuity benefit in respect of the “Waiting Periods”,
“Specific Waiting Periods” in the event of payment of premium within the stipulated grace
Period.
iv. No interest will be charged If the instalment premium is not paid on due date.
v. In case of instalment premium due not received within the grace period, the policy will get
cancelled.
vi. In the event of a claim, all subsequent premium instalments shall immediately become due
and payable.
vii. The company has the right to recover and deduct all the pending installments from the claim
amount due under the policy.
viii. However, premium payment mode under this rider Policy will be same as that of premium
payment mode chosen in Base Plan or it can be lump sum payment.

B. Cancellation
a. The Policyholder may cancel this Policy by giving 7 days’ written notice and in such an event,
the Company shall refund to the Insured a pro-rata premium for the unexpired Policy Period.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 5

HDHHLIP21335V022021
HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

Note : For Policies where premium is paid by instalment : In case of admissible claim under the Policy,
future instalment for the current Policy Year will be adjusted in the claim amount and no refund of
any premium will be applicable during the Policy Year.
b. The Company may cancel the Policy at any time on grounds of established fraud or non-
disclosure or misrepresentation by the Insured Person by giving 15 days’ written notice. There
would be no refund of premium on cancellation on grounds of established fraud or non-
disclosure or misrepresentation.
c. Refund of Policy premium in case of death of Insured Person/s: Policy premium shall be
refunded proportionately for the deceased Insured Person, for the unexpired Policy Period in
case of death of any Insured Person/s
d. Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made
in respect of Cancellation where any claim has been admitted or any benefit has been availed
by the Insured Person under the Policy.

C. Fraud
If any claim made by the insured person, is in any respect fraudulent, or if any false statement, or
declaration is made or used in support thereof, or if any fraudulent means or devices are used by the
insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits
under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent later shall
be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who shall be jointly and
severally liable for such repayment to the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts committed by the
insured person or by his agent or the hospital/doctor/any other party acting on behalf of the insured
person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:
a) the suggestion, as a fact of that which is not true and which the insured person does not believe to
be true;
b) the active concealment of a fact by the insured person having knowledge or belief of the fact;
c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of Fraud, if
the insured person / beneficiary can prove that the misstatement was true to the best of his knowledge
and there was no deliberate intention to suppress the fact or that such misstatement of or suppression
of material fact are within the knowledge of the insurer.

D. Free Look Period

The Free Look Period shall be applicable on new individual health insurance policies and not on renewals
or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of thirty days from date of receipt of the policy
document to review the terms and conditions of the policy, and to return the same if not acceptable.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 6

HDHHLIP21335V022021
HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

If the insured has not made any claim during the Free Look Period, the insured shall be entitled to
i. a refund of the premium paid less any expenses incurred by the Company on medical examination of
the insured person and the stamp duty charges or
ii. where the risk has already commenced and the option of return of the policy is exercised by the
insured person, a deduction towards the proportionate risk premium for period of cover or
Where only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
E. Renewal of Policy
A health insurance policy shall be renewable except on grounds of established fraud or non-disclosure or
misrepresentation by the insured, provided the policy is not withdrawn and also subject to conditions
stated under Moratorium clause of this schedule.
a) Renewal of a health insurance policy shall not be denied on the ground that the insured had made a
claim or claims in the preceding policy years, except for benefit based policies where the policy
terminates following payment of the benefit covered under the policy like critical illness policies.
b) The company shall condone a delay in renewal up to the grace period from the due date of renewal
without considering such condonation as a break in policy.
c) No loading shall apply on renewals based on individual claims experience
d) The Company shall not resort to fresh underwriting unless there is an increase in sum insured. In
case increase in sum insured is requested by the Policyholder, the Insurer may underwrite only to
the extent of increased sum insured.
e) Renewal premium due can be paid prior to the due date as per norms set out by the Company.
F. Notification of Claims
We must be informed of any event or occurrence that may give rise to a claim under this Policy within 30
days of it occurrence.
G. Moratorium Period
After completion of sixty continuous months of coverage (including portability and migration) in health
insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure,
misrepresentation, except on grounds of established fraud. This period of sixty continuous months is
called as moratorium period. The moratorium would be applicable for the sums insured of the first policy.
Wherever, the sum insured is enhanced, completion of sixty continuous months would be applicable from
the date of enhancement of sums insured only on the enhanced limits.
H. Claim Settlement (Provision for Penal Interest):
a. The Company shall settle or reject a claim, as the case may be, within 15 days from the date of
receipt of intimation.
b. In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the
Policyholder from the date of receipt of intimation to the date of payment of claim at a rate 2%
above the Bank Rate.
I. Grievance Redressal Procedure
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 7

HDHHLIP21335V022021
HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

In case of any grievance the insured person may contact the company through:

First Point of
Call us at 022 6158 2020 / 022 6234 6234/[Link]
Contact
For lack of a response or if the response provided does not meet your expectation,
you can:

1. Write to The Complaints & Grievance Cell (C&G Cell)

HDFC ERGO General Insurance Company Limited, D-301, 3rd Floor, Eastern
Level 1 Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai – 400078,
Maharashtra

2. You can also write an email to grievance@[Link]

3. Call on 18002677444 (operational Monday - Saturday 9AM to 6PM)

If you're not satisfied with the resolution or if no response was received within 15
days, you can:

1. Write to the Chief Grievance Officer

Level 2 HDFC ERGO General Insurance Company Limited, D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai – 400078,
Maharashtra

2. You can also write an email to cgo@[Link]

In case grievance is not resolved at the above escalation levels, you can also lodge
Level 3 an online complaint through the website of Council for Insurance Ombudsmen (CIO)
[Link]

Dedicated Helpline For Email ID Contact Number

Senior Citizen seniorcitizen@[Link] 022 6158 2026
Women - 022 6158 2055

You may also refer the Grievance Redressal Escalation matrix on our website
[Link]

If Insured Person is not satisfied with the redressal of grievance through above methods, the Insured
Person may also approach the office of Insurance Ombudsman of the respective area/region for redressal
of grievance as per Insurance Ombudsman Rules 2017.
Grievance may also be lodged at IRDAI Integrated Grievance Management System -
[Link]

Latest contact details of Offices of Insurance Ombudsman are provided at Annexure A.

II. Specific General Terms & Conditions

A. Non- Disclosure or Misrepresentation:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 8

HDHHLIP21335V022021
HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

I. If at the time of issuance of Policy or during continuation of the Policy, the information
provided to Us in the proposal form or otherwise, by You or the Insured Person or anyone
acting on behalf of You or an Insured Person is found to be incorrect, incomplete, suppressed
or not disclosed, wilfully or otherwise, the Policy shall be:
i. cancelled ab initio from the inception date or the renewal date (as the case may be), or the
Policy may be modified by Us, at our sole discretion, upon 15 day notice by sending an
endorsement to Your address shown in the Schedule; and
ii. the claim under such Policy if any, shall be prejudiced.

II. We may also exercise any of the below listed options for the purpose of continuing the health
insurance coverage in case of Non-Disclosure/Misrepresentation of Pre-existing diseases subject
to your prior consent;
i. Permanently exclude the disease/condition and continue with the Policy
ii. Incorporate additional waiting period of not exceeding 3 years for the said undisclosed disease
or condition from the date the non-disclosed condition was detected and continue with the
Policy.
iii. Levy underwriting loading from the first year of issuance of policy or renewal, whichever is
later.
The above options will not prejudice the rights of the Company to invoke cancellation under clause I
above.
B. Claim Payment - Important terms and conditions
i. Claim under this rider Policy will only be admissible when it qualifies according to the terms,
conditions and exclusions in the Base Plan.
ii. We shall be under no obligation to make any payment under this Policy unless We have
received all premium payments in full in time and all payments have been realized and We have
been provided with the documentation and information We have requested to establish the
circumstances of the claim, its quantum or Our liability for it, and unless the Insured Person has
complied with his obligations under this Policy.
iii. We will only make payment to You under this Policy. Receipt of payment by You shall be
considered as a complete discharge of Our liability against the respective claim under this
Policy. In the event of Your death, We will make payment to the Nominee (as named in the
Policy Schedule), payments under this Policy shall only be made in Indian Rupees within India.
iv. The assignment of benefits of the policy shall be subject to applicable law.
v. We are not obliged to make payment for any claim or that part of any claim that could have
been avoided or reduced if the Insured Person had not taken undue risk.
Claims Payment for instalment payments
Please note that following conditions will be applied for monthly, Quarterly and Half-yearly premium
payment options:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 9

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

i. In case of any Hospitalization claim, an amount equivalent to the balance of the instalment
premiums payable in the Policy Year, would be recoverable from the admissible claim amount
payable in respect of the Insured Person. This provision will not apply to claims arising under
Preventive Health Check-up.
ii. If the claim amount is lesser than the balance premium payable, then no claims would be
payable till the applicable premium is recovered. This provision will not apply to claims arising
under Preventive Health Check-up.
C. Policy Period
The policy will be issued for a period of 1, 2 & 3 year(s) period depending on the period of Base
Plan.
D. Loading
Premium of this Policy is dependent on premium of Base Plan. In case a risk loading is applied on
Base Policy leading to increase in premium of Base Plan, premium of this rider Policy will be
increased in commensuration with premium of Base Plan.
E. Discount
i. Discount of 7.5% on 2 years and 10% on 3years policy premiums when paid on lump sum
payment mode.
ii. Family Discount of 10% if 2 or more family members are covered under Individual Sum
Insured Plan of this Policy.
F. Waiting Period
There are no waiting periods in this Policy. However, this Policy shall follow waiting periods
applicable in Base Plan.

G. Notices
Any notice, direction or instruction under this Policy shall be in writing and if it is to:
i. Any Insured Person, it would be sent to You at the address specified in Schedule /
endorsement.
ii. Us, shall be delivered to Our address specified in the Schedule.
iii. No insurance agents, brokers, other person/ entity is authorised to receive any notice on Our
behalf.
H. Dispute Resolution Clause
Any and all disputes or differences under or in relation to this Policy shall be determined by the Indian
Courts and subject to Indian law.
I. All other conditions will be applicable as mentioned in the Base Plan.

SECTION E. OTHER TERMS & CONDITIONS

1. Claim Procedure
What do I do in case of a claim or any assistance?
Please quote your member ID/policy number in all your correspondences.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 10

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

Intimation & Assistance Procedure for Procedure to avail Cashless

Reimbursement of Medical facility
Expenses
Please use the Claim Intimation • Please send the duly signed • For any planned hospitalization,
Form (available on our website claim form and all the kindly seek cashless authorization
under Other Forms in the information/ documents from us at least 48 hours prior to
Downloads section) for mentioned* therein to us the hospitalization
intimation of a claim within 15 days of the • For any emergency
completion of the treatment Hospitalisation, We must be
For claims related to * Please refer to claim form informed no later than 24 hours
Planned Hospitalization: for complete after hospitalization
contact us at least 48 hours prior documentation • We will check your coverage as
to hospitalization • If there is any deficiency in per the eligibility and send an
the documents/information authorization letter to the
submitted by you, We will provider. In case there is any
For claims related to
send the deficiency letter deficiency in the documents sent,
unplanned or Emergency
within 7 days of receipt of the same shall be communicated
Hospitalization: contact us
the claim documents to the hospital within 1 hour of
within 24 hours of hospitalization
• The Company shall settle or receipt of documents
reject a claim, as the case • In case the ailment /treatment is
All the other benefits except may be, within 15 days from not covered under the policy a
Hospitalization: contact us the date of receipt of rejection letter would be sent to
Within 7 days of the Insured intimation. the provider within 1 hour
Person’s discharge post-
• The payment will be made in
hospitalization
the name of the proposer Note:
• Insured person is entitled for
Note: cashless only in our empaneled
Payment will only be made for hospitals
items covered under your Base • Please refer to the list of
Plan and up to the limits empaneled hospitals on our
therein. website Or the list provided in
the welcome kit
• Rejection of cashless in no way
indicates rejection of the claim

• We can be contacted through:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 11

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HDFC ERGO General Insurance Company Limited

Endorsement Document
Protector Rider

Within India
Customer Service No. 022-62346234 / 0120-62346234
Claim Intimation: Email: healthclaims@[Link]
Reimbursement Claim Intimation: Visit [Link] - > Help - >
Claim Registration
HDFC ERGO General Insurance Co. Ltd.
Claim document submission Stellar IT Park, Tower-1
at address: 5th Floor, C - 25, Sector 62
Noida – 0120 398 8360

Supporting Documentation & Examination

We may request any document to establish our liability towards a claim within 15 days of either Our
request or the Insured Person’s discharge from Hospital or completion of treatment, whichever is earlier.
The Company may accept claims where documents have been provided after a delayed interval only in
special circumstances and for the reasons beyond the control of the insured.
Following is the list of mandatory documents that need to be submitted with every claim:
i) Our claim form, duly completed and signed for on behalf of the Insured Person.
ii) Original Bills (including but not limited to pharmacy purchase bill, consultation bill, and diagnostic
bill) and any attachments thereto like receipts or prescriptions in support of any amount claimed
which will then become Our property.
iii) All reports and records, including but not limited to all medical reports, case histories, investigation
reports, treatment papers, discharge summaries.
iv) A precise diagnosis of the treatment for which a claim is made.
v) A detailed list of the individual medical services and treatments provided and a unit price for each
(detailed break up).
vi) Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their
price and a receipt for payment. Prescriptions must be submitted with the corresponding Doctor’s
invoice.
vii) All pre and post investigation, treatment and follow up (consultation) records pertaining to the
present ailment for which claim is being made.
viii) Regulatory requirements as amended from time to time, currently mandatory NEFT (to enable direct
credit of claim amount in bank account) and KYC (recent ID/Address proof and photograph)
requirements.
Below list of documents but not limited to the following, will have to be submitted on case to case basis:
i) Indoor Case Papers
ii) All investigation, treatment and follow up records pertaining to the past ailment(s) since their first
diagnoses.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 12

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iii) Treating doctor’s certificate regarding missing information in case histories e.g. Circumstance of
injury and Alcohol or drug influence at the time of accident.
iv) Copy of settlement letter from other insurance company or TPA.
v) Stickers and invoice of implants used during surgery.
vi) Copy of MLC (Medico legal case) records and FIR (First information report), in case of claims arising
out of an accident.
vii) Legal heir certificate. The Insured Person shall have to undergo medical examination by Our
authorized Medical Practitioner, as and when We may reasonably require, to obtain an independent
opinion for the purpose of processing any claim. We will bear the cost towards performing such
medical examination (at the specified location) of the Insured Person.
ANNEXURE A
Ombudsman Details
The contact details of the Insurance Ombudsman offices are as below-
Jurisdiction of Office
Office Details Union Territory, District)
AHMEDABAD
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Tilak Marg, Relief Road, Gujarat, Dadra & Nagar Haveli, Daman and Diu.
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02
Email: [Link]@[Link]
BENGALURU
Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-27-N-19
Ground Floor, 19/19, 24th Main Road, Karnataka.
JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: [Link]@[Link]
BHOPAL
Office of the Insurance Ombudsman,
1st floor,"Jeevan Shikha",
60-B,Hoshangabad Road,
Madhya Pradesh, Chhattisgarh.
Opp. Gayatri Mandir, Arera Hills
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202 / 2769203
Email: [Link]@[Link]
BHUBANESWAR
Office of the Insurance Ombudsman,
62, Forest park,
Bhubaneswar – 751 009. Odisha.
Tel.: 0674 - 2596461
/2596455/2596429/2596003
Email: [Link]@[Link]
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 13

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Jurisdiction of Office
Office Details Union Territory, District)
CHANDIGARH
Office Of The Insurance Ombudsman,
Jeevan Deep Building SCO 20-27, Punjab, Haryana (excluding Gurugram, Faridabad,
Ground Floor Sector- 17 A, Sonepat and Bahadurgarh), Himachal Pradesh, Union
Chandigarh – 160 017. Territories of Jammu & Kashmir,Ladakh & Chandigarh.
Tel.: 0172-2706468
Email: [Link]@[Link]
CHENNAI
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu, PuducherryTown and Karaikal (which are
Anna Salai, Teynampet,
part of Puducherry).
Chennai – 600 018.
Tel.: 044 - 24333668 / 24333678
Email: [Link]@[Link]

DELHI
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Delhi & following Districts of Haryana - Gurugram,
Asaf Ali Road,
Faridabad, Sonepat & Bahadurgarh.
New Delhi – 110 002.
Tel.: 011 - 46013992/23213504/23232481
Email: [Link]@[Link]
GUWAHATI
Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Assam, Meghalaya, Manipur, Mizoram, Arunachal
Near Pan Bazar , S.S. Road,
Pradesh, Nagaland and Tripura.
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205 / 2631307
Email: [Link]@[Link]
HYDERABAD
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Lane [Link] Showroom ,
Andhra Pradesh, Telangana, Yanam and part of Union
A. C. Guards, Lakdi-Ka-Pool,
Territory of Puducherry.
Hyderabad - 500 004.
Tel.: 040 - 23312122 / 23376991 /
23376599 / 23328709 / 23325325
Email: [Link]@[Link]
JAIPUR
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan.
Jaipur - 302 005.
Tel.: 0141- 2740363
Email: [Link]@[Link]

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 14

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Jurisdiction of Office
Office Details Union Territory, District)
KOCHI
Office of the Insurance Ombudsman,
10th Floor, Jeevan Prakash, LIC Building,
Kerala, Lakshadweep, Mahe-a part of Union Territory of
Opp to Maharaja's College Ground,
Puducherry.
[Link], Kochi - 682 011.
Tel.: 0484 - 2358759
Email: [Link]@[Link]
KOLKATA
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 7th Floor,
4, C.R. Avenue, West Bengal, Sikkim, Andaman & Nicobar Islands.
Kolkata - 700 072.
Tel.: 033 - 22124339 / 22124341
Email: [Link]@[Link]
Districts of Uttar Pradesh : Lalitpur, Jhansi, Mahoba,
Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur,
LUCKNOW
Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi,
Office of the Insurance Ombudsman,
Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
6th Floor, Jeevan Bhawan, Phase-II,
Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti,
Nawal Kishore Road, Hazratganj,
Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti,
Lucknow - 226 001.
Ambedkarnagar, Sultanpur, Maharajgang,
Tel.: 0522 - 4002082 / 3500613
Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Email: [Link]@[Link]
Deoria, Mau, Ghazipur, Chandauli, Ballia,
Sidharathnagar.
MUMBAI
Office of the Insurance Ombudsman, List of wards under Mumbai
3rd Floor, Jeevan Seva Annexe, Metropolitan Region excluding wards in Mumbai –
S. V. Road, Santacruz (W), i.e M/E, M/W, N, S and T covered under
Mumbai - 400 054. Office of Insurance Ombudsman Thane and
Tel.: 022 - 69038800/27/29/31/32/33 areas of Navi Mumbai.
Email: [Link]@[Link]
NOIDA State of Uttarakhand and the following Districts of Uttar
Office of the Insurance Ombudsman, Pradesh: Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
Bhagwan Sahai Palace Bulandshehar, Etah, Kannauj, Mainpuri, Mathura,
4th Floor, Main Road, Naya Bans, Sector 15, Meerut, Moradabad, Muzaffarnagar, Oraiyya, Pilibhit,
Distt: Gautam Buddh Nagar, U.P-201301. Etawah, Farrukhabad, Firozbad, Gautam Buddh nagar,
Tel.: 0120-2514252 / 2514253 Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli,
Email: [Link]@[Link] Rampur, Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
PATNA
Office of the Insurance Ombudsman,
2nd Floor, Lalit Bhawan,
Bailey Road, Bihar, Jharkhand.
Patna 800 001.
Tel.: 0612-2547068
Email: [Link]@[Link]
PUNE State of Goa and State of Maharashtra excluding areas
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 15

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Jurisdiction of Office
Office Details Union Territory, District)
Office of the Insurance Ombudsman, of Navi Mumbai, Thane district, Palghar District, Raigad
Jeevan Darshan Bldg., 3rd Floor, district & Mumbai Metropolitan Region
C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Narayan Peth, Pune – 411 030.
Tel.: 020-24471175
Email: [Link]@[Link]
THANE
Office of the Insurance Ombudsman,
2nd Floor,Jeevan Chintamani Building, Area of Navi Mumbai, Thane District, Raigad District,
Vasantrao Naik Mahamarg, Palghar District and wards of Mumbai, M/East,
Thane (West)- 400604 M/West, N, S and T."
Tel.: 022-20812868/69
Email: [Link]@[Link]

Annexure I – List of excluded items

Sr. Item Sr. Item
No. No.
1 BABY FOOD 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
HOSPITAL)
2 BABY UTILITIES CHARGES 36 SPACER
3 BEAUTY SERVICES 37 SPIROMETRE
4 BELTS/ BRACES 38 NEBULIZER KIT
5 BUDS 39 STEAM INHALER
6 COLD PACK/HOT PACK 40 ARMSLING
7 CARRY BAGS 41 THERMOMETER
8 EMAIL / INTERNET CHARGES 42 CERVICAL COLLAR
9 FOOD CHARGES (OTHER THAN 43 SPLINT
PATIENT'S DIET PROVIDED BY
HOSPITAL)
10 LEGGINGS 44 DIABETIC FOOT WEAR
11 LAUNDRY CHARGES 45 KNEE BRACES (LONG/ SHORT/ HINGED)
12 MINERAL WATER 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
13 SANITARY PAD 47 LUMBO SACRAL BELT
14 TELEPHONE CHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES
15 GUEST SERVICES 49 AMBULANCE COLLAR
16 CREPE BANDAGE 50 AMBULANCE EQUIPMENT

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 16

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17 DIAPER OF ANY TYPE 51 ABDOMINAL BINDER

18 EYELET COLLAR 52 PRIVATE NURSES CHARGES- SPECIAL NURSING
CHARGES
19 SLINGS 53 SUGAR FREE TABLETS
20 BLOOD GROUPING AND CROSS 54 CREAMS POWDERS LOTIONS (TOILETRIES ARE NOT
MATCHING OF DONORS PAYABLE, ONLY PRESCRIBED MEDICAL
SAMPLES PHARMACEUTICALS PAYABLE)
21 SERVICE CHARGES WHERE 55 ECG ELECTRODES
NURSING CHARGE ALSO
CHARGED
22 TELEVISION CHARGES 56 GLOVES
23 SURCHARGES 57 NEBULISATION KIT
24 ATTENDANT CHARGES 58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY
KIT, ORTHOKIT, RECOVERY KIT, ETC]
25 EXTRA DIET OF PATIENT 59 KIDNEY TRAY
(OTHER THAN THAT WHICH
FORMS PART OF BED CHARGE)
26 BIRTH CERTIFICATE 60 MASK
27 CERTIFICATE CHARGES 61 OUNCE GLASS
28 COURIER CHARGES 62 OXYGEN MASK
29 CONVEYANCE CHARGES 63 PELVIC TRACTION BELT
30 MEDICAL CERTIFICATE 64 PAN CAN
31 MEDICAL RECORDS 65 TROLLY COVER
32 PHOTOCOPIES CHARGES 66 UROMETER, URINE JUG
33 MORTUARY CHARGES 67 AMBULANCE
34 WALKING AIDS CHARGES 68 VASOFIX SAFETY

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office:
6th Floor, Leela Business Park, Andheri- Kurla Road, Andheri (East), Mumbai – 400 059. UIN: Protector Rider- 17

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